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No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework. Systematic review and modified narrative synthesis. Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery. The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.
Leamy M, Bird V, Le Boutillier C, Williams J, Slade M A conceptual framework for personal
recovery in mental health: systematic review and narrative synthesis, British Journal of Psychiatry,
in press.
A conceptual framework for personal recovery in mental health:
systematic review and narrative synthesis
Mary Leamy*#
Victoria Bird#
Clair Le Boutillier
Julie Williams
Mike Slade
King’s College London, Institute of Psychiatry
* Corresponding author
# Joint first author
No systematic review and narrative synthesis on personal recovery in mental illness has been
To synthesise published descriptions and models of personal recovery into an empirically-based
conceptual framework.
Systematic review and modified narrative synthesis.
97 papers were included from 5,208 papers identified and 366 reviewed. The emergent conceptual
framework consists of: i) thirteen Characteristics of the Recovery Journey; ii) five Recovery
Processes comprising Connectedness, Hope and optimism about the future, Identity, Meaning in
life and Empowerment (giving the acronym CHIME); and iii) Recovery Stage descriptions which
mapped onto the Transtheoretical Model of Change
. Studies focussed on recovery for Black and
Minority Ethnic (BME) individuals showed a greater emphasis on Spirituality and Stigma and also
identified two additional themes: Culturally specific facilitating factors and Collectivist notions of
The conceptual framework is a theoretically-defensible and robust synthesis of people’s
experiences of recovery in mental illness. This provides an empirical basis for future recovery-
oriented research and practice.
Declaration of interest
Personal recovery has been defined as “a deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills and/or roles…a way of living a satisfying, hopeful and
contributing life even with the limitations caused by illness
. A recovery orientation is mental
health policy in most Anglophone countries. For example, the mental health plan for England
2009-2019 has the “expectation that services to treat and care for people with mental health
problems will be…based on the best available evidence and focused on recovery, as defined in
discussion with the service user
. The implications of a recovery orientation for working practice
are unclear, and guidelines for developing recovery-orientated services are only recently becoming
. Comprehensive reviews of the recovery literature have concluded that there is a need
for conceptual clarity on recovery
. Current approaches to understanding personal recovery are
primarily based on qualitative research
or consensus methods
. No systematic review and
synthesis of personal recovery in mental illness has been undertaken.
The aims of this study were (i) to undertake the first systematic review of the available literature
on personal recovery and (ii) to use a modified narrative synthesis to develop a new conceptual
framework for recovery. A conceptual framework, defined as “a network, or a plane, of interlinked
concepts that together provide a comprehensive understanding of a phenomenon or phenomena
provides an empirical basis for future recovery-oriented research and practice.
Eligibility criteria
The review sought to identify papers that explicitly described or developed a conceptualisation of
personal recovery from mental illness. A conceptualisation of recovery was defined as either a
visual or narrative model of recovery, or themes of recovery, which emerged from a synthesis of
secondary data or an analysis of primary data. Inclusion criteria for studies were: (i) contains a
conceptualisation of personal recovery from which a succinct summary could be extracted; (ii)
presented an original model or framework of recovery; (iii) was based on either secondary research
synthesising the available literature or primary research involving quantitative or qualitative data
based on at least three participants; (iv) was available in printed or downloadable form; (v) was
available in English. Exclusion criteria were: (a) studies solely focussing upon clinical recovery
(i.e. using a predefined and invariant ‘getting back to normal’ definition of recovery through
symptom remission and restoration of functioning); (b) studies involving modelling of predictors
of clinical recovery; (c) studies defining remission criteria or recovery from substance misuse,
addiction or eating disorders; and (d) dissertations and doctoral theses (due to article availability).
Search strategy and data sources
Three search strategies were used to identify relevant studies: electronic database searching, hand
searching and web based searching.
1. Twelve bibliographic databases were initially searched using three different interfaces: AMED;
British Nursing index; EMBASE; MEDLINE; PsycINFO; Social Science Policy (accessed via
OVID SP); CINAHL; International Bibliography of Social Science (accessed via EBSCOhost
and ASSIA); British Humanities Index; Sociological abstracts; and Social Services abstracts
(accessed via CSA Illumina). All databases were searched from inception to September 2009
using the following terms identified from the title, abstract, key words or medical subject
headings: ( ‘mental health’ OR ‘mental illness$’ OR ‘mental disorder’ OR mental disease’ OR
‘mental problem’) AND ‘recover$’ AND (‘theor$’, OR ‘framework’, OR ‘model’, OR
‘dimension’, OR ‘paradigm’ OR ‘concept$’). The search was adapted for the individual
databases and interfaces as needed. For example, CSA Illumina only allows the combination of
three ‘units’ each made up of three search terms at any one time e.g. (‘mental health’ OR
‘mental illness*’ OR ‘mental disorder’) AND ‘recover*’ AND (‘theor$’ OR ‘framework’ OR
‘concept’). As a sensitivity check, ten papers were identified by the research team as highly
influential, based on number of times cited and credibility of the authors (included papers 3, 9,
10, 19, 29, 34, 35, 40, 68 and 75 in Online Data Supplement 1). These papers were assessed for
additional terms, subject headings and key words, with the aim of identifying relevant papers
not retrieved using the original search strategy. This led to the use of the following additional
search terms: (‘psychol$ health’ OR ‘psychol$ illness$’ OR ‘psychol$ disorder’ OR psychol$
problem’ OR ‘psychiatr$ health’, OR psychiatr$ illness$’ OR ‘psychiatr$ disorder’ OR
‘psychiatr$ problem’) AND ‘recover$’ AND (‘theme$’ OR ‘stages’ OR ‘processes’).
Duplicate articles were removed within the original database interfaces using Reference
Manager Software Version 11.
2. The table of contents of journals which published key articles (Psychiatric Rehabilitation
Journal, British Journal of Psychiatry and American Journal of Psychiatry) and recent literature
reviews of recovery (included papers 4, 37 and 89 in Online Data Supplement 1) were hand-
3. Web-based resources were identified by internet searches using Google and Google Scholar
and through searching specific recovery-orientated websites (Scottish Recovery Network:; Boston University Repository of Recovery Resources:; Recovery Devon:; and
Social Perspectives Network:
Data Extraction and Quality Assessment
One rater (VB) extracted data and assessed the eligibility criteria for all retrieved papers with a
random sub-sample of 88 papers independently rated by a second rater (JW or CL). Disagreements
between raters were resolved by a third rater (ML). Acceptable concordance was predefined as
agreement on at least 90% of ratings. A concordance of 91% agreement was achieved. Data were
extracted and tabulated for all papers rated as eligible for the review.
Included qualitative papers were initially quality assessed by three raters (VB, JW and CL) using
the RATS qualitative research review guidelines
. The RATS scale comprises 25 questions about
the relevance of the study question, appropriateness of qualitative method, transparency of
procedures, and soundness of interpretive approach. In order to make judgements about quality of
papers, we dichotomised each question to yes (1 point) or no (0 points), giving a scale ranging
from 0 (poor quality) to 25 (high quality). A random sub-sample of 10 qualitative studies were
independently rated using the RATS guidelines by a second rater (ML). The mean score from
rating 1 was 14.8 and from rating 2 was 15.1, with a mean difference in ratings of 0.3 indicating
acceptable concordance. The Effective Public Health Practice Project (EPHPP)
assessment tool for quantitative studies was used to rate the two quantitative studies. Independent
ratings were made by two reviewers (VB, ML) of Ellis and King
and Resnick and colleagues
who agreed on rating both papers as moderate.
Data Analysis
The conceptual framework was developed using a modified narrative synthesis approach
. The
three stages of the narrative synthesis comprised: 1) Developing a preliminary synthesis; 2)
Exploring relationships within and between studies; and 3) Assessing the robustness of the
synthesis. For clarity, the development of the conceptual framework (Stages 1 and 3) is presented
in the Results before the sub-group comparison (Stage 2).
Stage 1: Developing a preliminary synthesis
A preliminary synthesis was developed using tabulation, translating data through thematic analysis
of good quality primary data, and vote counting of emergent themes. For each included paper, the
following data were extracted and tabulated: type of paper, methodological approach, participant
information and inclusion criteria, study location, and summary of main study findings. An initial
coding framework was developed and used to thematically analyse a sub-sample of qualitative
research studies with the highest RATS quality rating (i.e. RATS score of 15 or above), using
NVIVO QSR International qualitative analysis software (Version 8). The main over-arching
themes and related sub-themes occurring across the tabulated data were identified, using inductive,
open coding techniques. Additional codes were created by all analysts where needed and these new
codes were regularly merged with the NVIVO master copy and then this copy was shared with
other analysts, so all new codes were applied to the entire sub-sample.
Finally, once the themes had been created, vote counting was used to identify the frequency with
which themes appeared in all of the 97 included papers. The vote count for each category
comprised the number of papers mentioning either the category itself or a subordinate category. On
completion of the thematic analysis and vote counting, the draft conceptual framework was
discussed and refined by all authors. Some new categories were created, and others were subsumed
within existing categories, given less prominence or deleted. This process produced the
preliminary conceptual framework.
Stage 2: Exploring relationships within and between studies
Papers were identified from the full review which reported data from people from Black and
Minority Ethnic (BME) backgrounds. These papers were thematically analysed separately, and the
emergent themes compared to the preliminary conceptual framework. The thematic analysis
utilised a more fine-grained approach, in which a 2nd analyst (VB) went through the papers in a
detailed and line-by-line manner. The aim of the sub-group analysis was to specifically identify
any additional themes as well as any difference in emphasis placed on areas of the preliminary
framework. The aim was to identify areas of different emphasis in this sub-group of studies, rather
than being a validity check.
Stage 3: Assessing robustness of the synthesis
Two approaches were used to assess the robustness of the synthesis. First, qualitative studies
which were rated as moderate quality on the RATS scale (i.e. RATS score of 14) were
thematically analysed until category saturation was achieved. The resulting themes were then
compared with the preliminary conceptual framework developed in Stages 1 & 2. Second, the
preliminary conceptual framework was sent to an expert consultation panel. The panel comprised
54 advisory committee members of the REFOCUS Programme (see for
further details) who had either academic, clinical or personal expertise about recovery. They were
asked to comment on the positioning of concepts within different hierarchical levels of the
conceptual framework, identify any important areas of recovery which they felt had been omitted
and make any general observations. The preliminary conceptual framework was modified in
response to these comments, to produce the final conceptual framework.
The flow diagram for the 97 included papers is shown in Figure 1.
Insert Figure 1 here
The 97 included papers are shown in Online Data Supplement 1.
Insert Online Data Supplement 1 here
The 97 papers comprised qualitative studies (n=37), narrative literature reviews (n=20), book
chapters (n=7), consultation documents reporting the use of consensus methods (n=5), opinion
pieces or editorials (n=5), quantitative studies (n=2), combining of a narrative literature review
with personal opinion or where there is insufficient information on method for a judgement to be
made (n=11), and elaborations of other identified papers (n=10). In summary, 87 distinct studies
were identified. The ten elaborating papers were included in the thematic analysis but not the vote
counting (included papers 11, 15, 16, 19, 26, 48, 50, 53, 71 and 73 shown in Online Data
Supplement 1).
The 97 papers described studies conducted in 13 countries, including the United States of America
(n=50), United Kingdom (n=20), Australia (n=8) and Canada (n=6). Participants were recruited
from a range of settings including community mental health teams and facilities, self help groups,
consumer-operated mental health services and supported housing facilities. The majority of studies
used inclusion criteria that covered any diagnosis of severe mental illness. A few studies only
included participants who had been diagnosed with a specific mental illness (e.g. schizophrenia,
depression). The sample sizes in qualitative data papers ranged from 4 to 90 participants, with a
mean sample size of 27. The sample sizes in the two quantitative papers were 19 (pilot study of 15
service users and 4 case managers using a recovery interventions questionnaire
) and 1,076
(representative survey of people with schizophrenia
). The former was a pilot study of 15 service
users with experience of psychotic illness and 4 case managers using a Recovery Interventions
Questionnaire, carried out in Australia. The latter study analysed data from two sources, the
Schizophrenia Patient Outcomes Research Team (PORT) client survey, which examined usual care
in a random sample of people with schizophrenia in two US states and an extension to this survey
which provided a comparison group.
There were various approaches to determining the stage of recovery of participants. Most studies
rated stage of recovery using criteria such as: i) the person defined themselves as ‘being in
recovery’; ii) not hospitalised during the previous 12 months, iii) relatively well and symptom free;
iv) providing peer support to others; or v) working or living in semi-independent settings. Only a
few studies specifically used professional opinion - clinical judgement or scores on clinical
assessments - about whether people were recovered.
The mean RATS score for the 36 qualitative studies was 14.9 (range 8 to 20). One qualitative
study was not rated using the RATS guidelines because there was insufficient information on
methodology within this paper. A RATS score of 15 or above, indicating high quality was obtained
by 16 papers and used to develop a preliminary synthesis. A RATS score of 14, indicating
moderate quality, was obtained by five papers. Independent ratings were made of the two
quantitative papers, Ellis and King
and Resnick and colleagues
which were rated as moderate
by two reviewers (VB + ML). Given this quality assessment, no greater weight was put on the
quantitative studies in developing the category structure.
Conceptual framework for Personal Recovery
A preliminary conceptual framework was developed, which comprised five super-ordinate
categories: Values of recovery, Beliefs about recovery, Recovery-promoting attitudes of staff,
Constituent processes of recovery, and Stages of recovery.
The robustness of the synthesis underpinning the preliminary conceptual framework was assessed
in two steps; by re-analysing a sub-sample of qualitative studies and through expert consultation.
Sub-sample re-analysis
In addition to the higher quality qualitative studies analysed in the preliminary synthesis stage, an
additional five moderate quality (RATS score of 14) qualitative studies were analysed, which
confirmed that category saturation had been achieved, indicating that the categories are robust.
Expert consultation
A response was received from 23 (43%) of the 54 consulted experts with international and national
academic, clinical, and/or personal expertise and experiences of recovery, who are advisory
committee members of the REFOCUS programme into recovery. Responses were themed under
the following headings: Conceptual (dangers of reductionism, separating processes from stages,
confusing critical impetus for behaviours with actual behaviour, limitations of stage models);
Structural (complete omissions, lack or over-emphasis upon specific areas of recovery), Language
(too technical); and Bias (potential geographical bias). In response to this consultation, the
preliminary conceptual framework was simplified, so the final conceptual framework now has
three rather than five super-ordinate categories. Some sub-categories were re-positioned within
Recovery Processes, and some category headings changed. Some responses identified areas of
omission, such as the role of past trauma, hurt, and physical health in recovery. However, no
alteration was made to the conceptual framework as these did not emerge from the thematic
analysis. Other points around the strengths and limitations of the framework are addressed in the
Discussion. Overall, the expert consultation process provided a validity check on content of
conceptual framework, whilst we were careful to not to make radical changes which would have
been unjustified, given the weight of evidence provided from preliminary analysis of the included
The final conceptual framework comprises three inter-linked, super-ordinate categories:
Characteristics of the Recovery Journey; Recovery Processes; and Recovery Stages.
Characteristics of the Recovery Journey were identified in all 87 studies, and vote-counting was
used to indicate their frequency, shown in Table 1.
Insert Table 1 here
The categories of Recovery Processes and their vote counts, indicating frequency of the process
being identified, for the two highest category levels are shown in Table 2.
Insert Table 2 here
The full description of Recovery Processes categories and the vote counting results are shown in
Online Data Supplement 2.
Insert Online Data Supplement 2 here
Fifteen studies developed Recovery Stage models. The studies were organised using the
Transtheoretical Model of Change
, as shown in Table 3.
Insert Table 3 here
Recovery in Black and Minority Ethnic (BME) individuals
As part of stage two of the narrative synthesis process, six studies of recovery from the perspective
of BME individuals were identified within the 87 studies. These six studies were re-analysed by a
second analyst (VB), using a more fine-grained, line-by-line approach to thematic analysis. These
comprised a survey of 50 recipients of a community development project in Scotland
, a
qualitative interview study of African-Americans
, a narrative literature review
, a qualitative
study of 40 Maori and non-Maori New Zealanders
, a pilot study to test whether the Recovery
Star measure was applicable to Black and Asian Ethnic Minority population
and a mixed method
study of 91 males from African-Caribbean backgrounds
. These papers provide some preliminary
insights into a small number of distinct ethnic minority perspectives, which do not represent a
culturally homogenous group, although some similarities in experience can be observed. Although
these six papers were included in the vote counting process, four of the six BME papers
not used in the first stage thematic analysis. The line-by-line secondary analysis allowed us to
explore in greater detail any differences in emphasis and additional themes present in these papers.
The main finding of the sub-group analysis indicated that there was substantial similarity between
studies focussing on minority communities and those focussing on majority populations. All of the
themes of the conceptual framework were present in all six of the BME papers. Despite this overall
similarity, there was a greater emphasis in the BME papers on two areas in the Recovery
Processes: Spirituality and Stigma; and two additional categories: Culturally specific factors; and
Collectivist notions of recovery.
In relation to Spirituality, being part of a faith community and having a religious affiliation was
seen as an important component of an individual’s recovery. People from ethnic minorities more
often described spirituality in terms of religion and a belief in God as a higher power, whereas the
non-BME studies tended to conceptualise spirituality as encompassing a wider range of beliefs and
In relation to Stigma, BME studies emphasised the stigma associated with race, culture and
ethnicity, in addition to the stigma associated with having a mental illness. Furthermore, being an
individual from a minority ethnic group seemed to accentuate the stigma of mental illness, as the
person often viewed themselves as belonging to multiple stigmatised and disadvantaged groups.
Individuals from ethnic minorities saw themselves as recovering from racial discrimination, stigma
and violence, and not just from a period of mental illness.
The new category of Culturally specific factors included the use of traditional therapies, faith
healers and belonging to a particular cultural group or community. Finally, collectivist notions of
recovery were emphasised as both positive and negative factors. Many individuals discussed the
hope and support they received from their collectivist identity, but for others the community added
to the pressures of mental illness. This was particularly true where communities lacked
information and awareness regarding mental illness. Furthermore, the negative impact of the
community was felt not only at the level of the individual, but also at the collectivist level, with the
whole family being adversely affected by stigma.
This is the first systematic review and narrative synthesis of personal recovery. A conceptual
framework was developed using a narrative synthesis which identified three super-ordinate
categories: Characteristics of the Recovery Journey, Recovery Processes and Recovery Stages. For
each super-ordinate category, key dimensions were synthesised. The Recovery Processes, which
have the most proximal relevance to clinical research and practice, can be summarised using the
acronym CHIME. The robustness of the category structure was enhanced by the systematic nature
of the review, the quality assessment of included studies, the category saturation reached in the
analysis, and the content validity of the expert consultation. Heterogeneity between studies was
explored descriptively. A sub-group comparison between the experiences of recovery from the
perspective of BME individuals identified similar themes, with a greater emphasis on Spirituality
and, Stigma, and two additional themes: Culturally specific factors, and Collectivist notions of
Implications for research and practice
Key knowledge gaps have been identified as the need for clarity about the underpinning
philosophy of recovery
, better understanding of the stages and processes of recovery
, and valid
measurement tools
. This study can inform each of these gaps.
Recovery has been conceptualised as a vision, a philosophy, a process, an attitude, a life
orientation, an outcome and a set of outcomes
. This has led to the concern that its scope can
make a cow-catcher on the front of a road train look discriminating
. An empirically-based
conceptual framework can bring some order to this potential chaos. Characteristics of the
Recovery Journey provide conceptual clarity about the philosophy. Recovery Processes can be
understood as measurable dimensions of change which typically occur during recovery, and
provide a taxonomy of recovery outcomes
. Finally, Recovery Stages provide a framework for
guiding stage-specific clinical interventions and evaluation strategies.
The framework contributes to understanding about stages and processes of recovery in two ways.
First, it allows available evidence to be more easily identified. A recovery orientation has overlap
with the literature on well-being
, positive psychology
and self-management
, and systematic
reviewing is hampered by the absence of relevant MeSH (Medical Sub-Headings) headings
relating to recovery concepts. The coding framework provides key-words for use when
undertaking secondary research, and the identification of related terms provides a taxonomy which
will be useable in reviews.
Second, the framework provides a structure around which research and clinical efforts can be
oriented. The relative contribution of each Recovery Process, investigating interventions which can
support these processes, and the synchrony between recovery processes and stages are all testable
research questions. For clinical practice, the CHIME recovery processes support reflective
practice. If the goal of mental health professionals is to support recovery then one possible way
forward is for each working practice to be evaluated in relation to its impact on these processes.
This has the potential to contribute to current debates about recovery and, for example, assertive
, risk
and community psychiatry
Finally, the conceptual framework can contribute to the development of measures of personal
recovery. Compendia of existing measures have been developed
, showing that the conceptual
basis of measures is diverse. The conceptual framework provides a foundation for developing
standardised recovery measures, and is the basis for a new measure currently being developed by
the authors to evaluate the contribution of mental health services to an individual’s recovery. The
challenge will then be to incorporate a focus on recovery outcomes, and associated concepts such
as well-being
, into routine clinical practice
The study has three methodological and two conceptual limitations. The first methodological
limitation is that the narrative synthesis approach was modified, and could have been widened. For
example, the exploration in Stage 2 of relationships between studies could have considered the
sub-group of studies which had higher levels of consumer involvement in their design, but it
proved impossible to reliably rate identified studies in this dimension. The second technical
limitation is that the emergent categories were only one way of grouping the findings, and the
categories changed as a result of expert consultation. In particular, the three super-ordinate
categories are not separate, since processes clearly occur within the identified stages, and the
characteristics of recovery describe an overall movement through stages of recovery. Our
categorical separation brings structure, but a replication study may not arrive at the same overall
thematic structure. The final technical limitation is that analysis synthesised the interpretation in
the paper of the primary data in each paper, rather than considering the primary data directly.
Future research could compare papers generated by different stakeholder groups, such as consumer
researchers, clinical researchers, and policy-makers.
The first conceptual limitation is that this review, whilst synthesising the current literature on
personal recovery, should not be seen as definitive. A key scientific challenge is that the
philosophy of recovery gives primacy to individual experience and meaning (‘idiographic’
knowledge), whereas mental health systems and current dominant scientific paradigms give
prominence to group-level aggregated data (‘nomothetic’ knowledge)
. The practical impact is that
current recovery research is primarily focussed at the bottom of the hierarchy of evidence
. This
was our finding, with qualitative, case study and expert opinion methodologies dominating. A
motivator for the current study was to provide evidence of the form viewed as high quality within
the current scientific paradigm, but several of our expert consultants highlighted the dangers of
closing down discourse. Since recovery is individual, idiosyncratic and complex, this review is not
intended to be a rigid model of what recovery ‘is’. Rather, it is better understood as a resource to
inform future research and clinical practice. The second conceptual limitation relates to the sub-
group analysis looking at papers focusing on non-majority populations. Due to a lack of research,
it was not possible to look at the experience and perspectives of individuals from different minority
groups. Therefore, the BME sub-group represents a heterogeneous and incredibly diverse set of
populations. However, it was felt that all the populations included in these papers, shared a
common experience of belonging to minority ethnic group, and that this experience may have
important implications to the meaning of personal recovery, and to the experience of mental health
services in general. The lack of data coupled with the areas of difference found in the present
review, highlights a need for further work to be conducted with people from minority ethnic
Future research
This systematic review and narrative synthesis has highlighted the dominance of recovery
literature emanating from USA. Culturally, the USA neglects character strengths such as patient
and tolerance
, and favours individualistic over collectivist understandings of identity. Although
there were very few studies which looked at recovery experiences of individuals from BME
backgrounds, the sub-sample of BME studies indicated that there are important differences in
emphasis. There is a need for research to be conducted using a more diverse samples of people
from different ethnic and cultural backgrounds, at differing stages of recovery and experiencing
different types of mental illness.
The complexity of personal recovery requires a range of theoretical inquiry positions. This review
focussed on research into first-person accounts of recovery, where individual meanings of recovery
have dominated. This has led to a framework which may under-emphasise the importance of the
wider socio-environmental context, including important aspects such as stigma and discrimination.
Viewing recovery within an ecological framework, as suggested by Onken and colleague
encompasses an individual’s life context (characteristics of the individual, such as hope and
identity) as well as environmental factors (such as opportunities for employment and community
integration) and the interaction between the two (such as choice). A more complete understanding
of recovery requires greater attention to all these levels of understanding, for instance, upon how
power is related to characteristics of individuals or groups (e.g. race and culture), how clinicians
and patients interact within different stages of recovery and how these interactions change over
time. There is also a need for future research to increase our understanding of how subtle micro-
processes of recovery are operating, such as how hope is reawakened and sustained.
Supporting Recovery Processes may be the future mental health research priority. The 13
dimensions identified as Characteristics of the Recovery Journey capture much of the experience
and complexities of recovery, and further research may not have a high scientific pay-off.
Similarly, although the Recovery Stages could be mapped onto the Transtheoretical Model of
, there was little consensus about the number of recovery phases. It may therefore be more
helpful to undertake evaluative research addressing specific service-level questions (such as
whether people using a service are making recovery gains over time
or in different service
), rather than further studies seeking conceptual clarity. Overall, the emergent priority is
the development and evaluation of interventions to support the five CHIME Recovery Processes.
The subordinate categories point to the need for a greater emphasis on assessment of strengths and
support for self-narrative development, a new construction of the contribution of the mental health
system being as much about developing inclusive communities and enabling access to peer support
as providing treatments, and clinical interaction styles which promote empowerment and self-
management. The CHIME categories are potential clinical end-points for interventions, in contrast
with the current dominance of clinical recovery end-points such as symptomatology or
hospitalisation rates. They also provide a framework for empirical investigation of the relationship
between recovery outcomes, using methodologies developed in relation to clinical outcomes
This area of enquiry is currently small
but an important priority if potential trade-offs between
desirable outcomes are to be identified
Orienting mental health services towards recovery will involve system transformation
. The
research challenge is to develop an evidence base which simultaneously helps mental health
professionals to support recovery and respects the understanding that recovery is a unique and
individual experience rather than something the mental health system does to a person. This
conceptual framework for personal recovery, which has been developed through a systematic
review and narrative synthesis, provides a useful starting point for meeting this challenge.
This study was funded by a National Institute for Health Research (NIHR) Programme Grant for
Applied Research (RP-PG-0707-10040) awarded to the South London and Maudsley NHS
Foundation Trust, and in relation to the NIHR Specialist Mental Health Biomedical Research
Centre at the Institute of Psychiatry, King’s College London. The views expressed in this
publication are those of the authors and not necessarily those of the NHS, the NIHR or the
Department of Health. We would also like to acknowledge Popay et al. for giving us the
unpublished guidance on narrative synthesis.
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Figure 1: Flow chart to show assessment of eligibility of identified studies
Identified papers n=5,208
Electronic databases (after duplicates removed) 5,169
Additional papers identified from hand searching, web-based
articles and citations 39
Excluded from title n = 4,389
Clearly not relevant (n = 4,085)
Population (n = 239)
Not in English (n = 65)
Abstracts review n = 819
Full papers retrieved n = 366
Excluded based on abstract n=443
Included n = 97
Excluded based on paper n=269
No succinct model or
conceptualisation (n=118)
Uses an existing model (n= 110)
Not relevant (n=24)
Population (n= 9)
Focus on clinical recovery (n= 8)
Table 1: Characteristics of the Recovery Journey
Dimension Number (%) of 87 studies
identifying the dimension
Recovery is an active process 44 (50%)
Individual and unique process 25 (29%)
Non-linear process 21 (24%)
Recovery as a journey 17 (20%)
Recovery as stages or phases 15 (17%)
Recovery as a struggle 14 (16%)
Multi-dimensional process 13 (15%)
Recovery is a gradual process 13 (15%)
Recovery as a life-changing experience 11 (13%)
Recovery without cure 9 (10%)
Recovery is aided by supportive and healing environment 6 (7%)
Recovery can occur without professional intervention 6 (7%)
Trial and error process 6 (7%)
Table 2. Recovery Processes
Recovery Processes Number (%) of 87 studies
identifying the process
Category 1: Connectedness
75 (86%)
Peer support and support groups
39 (45%)
33 (38%)
Support from others
53 (61%)
Being part of the community
35 (40%)
Category 2: Hope and optimism about the future
69 (79%)
Belief in possibility of recovery
30 (34%)
Motivation to change
Hope inspiring relationships 15 (17%)
12 (14%)
Positive thinking and valuing success
10 (11%)
Having dreams and aspirations
7 (8%)
Category 3: Identity
65 (75%)
Dimensions of identity
8 (9%)
Rebuilding/redefining positive sense of identity
57 (66%)
Over-coming stigma 40 (46%)
Category 4: Meaning in life
59 (66%)
Meaning of mental illness experiences
30 (34%)
6 (41%)
Quality of life
Meaningful life and social roles
Meaningful life and social goals
57 (65%)
40 (46%)
15 (17%)
Rebuilding life
19 (22%)
Category 5: Empowerment
79 (91%)
Personal responsibility
79 (91%)
Control over life
78 (90%)
Focussing upon strengths
14 (16%)
Table 3: Recovery stages mapped on to Transtheoretical Model of Change
Online Data
Precontemplation Contemplation Preparation Action Maintenance &
32 Novitiate recovery:
Struggling with
Semi-recovery –
living with
Full recovery – living
beyond disability
73 Stuck Accepting help Believing Learning Self-reliant
3 Descent into hell Igniting a spark of
hope Developing
instinct to fight
Discovering keys
to well-being Maintaining
equilibrium between
internal and external
44 Demoralisation Developing &
Efforts towards
36 Occupational
dependence Supported
Active engagement
in meaningful
14 Dependent/unaware Dependent/aware Independent/aware Interdependent/aware
29 Moratorium Awareness Preparation Rebuilding Growth
78 Glimpses of
recovery Turning points Road to recovery
Reawakening of
hope after despair No longer
viewing self as
person with
Moving from
withdrawal to
Active coping rather
than passive
40 Overwhelmed by the
disability Struggling with
the disability Living with the
disability Living beyond the
35 Initiating recovery Regaining what
was lost/moving
Improving quality of
59 Crisis (recuperation) Decision
(building healthy
43 Turning point Determination Self-esteem
Data Supplements (in separate files)
Online Data Supplement 1: Included papers (n=97)
Online Data Supplement 2: Full list of categories and vote counting for Recovery Processes
Author contributions
All authors contributed to the conception and design, drafting and revising the article,
and gave approval to the final version. Mike Slade is the Principal Investigator.
Author details
(Corresponding author) Mary Leamy PhD, Programme Co-ordinator
King’s College London, Health Service and Population Research Department (Box
P029), Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF
Tel: 020 7848 5095
Fax: 020 7277 1462
Mike Slade PhD PsychD
Clair Le Boutillier MSc
Julie Williams MSc
Victoria Bird BSc
All at King’s College London, Health Service and Population Research Department
(Box P029), Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5
... The implementation of the recovery model has thus resulted in a number of important shifts, including the prioritisation of service user lead definitions of recovery when providing support. Whilst recovery is understood to be an idiosyncratic process and competing definitions (clinical vs service user) have been proposed, a range of models have been developed (e.g., CHIME; [7]). These models highlight that there are common features of recovery shared across individuals, including, connection, hope, empowerment, and meaning in life, to name a few [7][8][9]. ...
... Whilst recovery is understood to be an idiosyncratic process and competing definitions (clinical vs service user) have been proposed, a range of models have been developed (e.g., CHIME; [7]). These models highlight that there are common features of recovery shared across individuals, including, connection, hope, empowerment, and meaning in life, to name a few [7][8][9]. This line of research enquiry has facilitated the production of guidelines and tools for developing recovery focused services and practices within mental health [10,11]. ...
... Specifically, our sample is made up of predominantly White British individuals, as such the findings are limited in terms of their generalisability to other cultures. This is of significant importance because evidence suggests that there are aspects of recovery which are unique to those belonging to Black and Minority Ethnic communities [7]. This, along with our choice of convenience sampling can limit the generalisability of the present findings. ...
Full-text available
Background Understanding recovery in mental health has received significant attention and consequently, recovery has been incorporated into health policy across many countries in the Global North. In comparison, the concept of ‘recovery’ from suicidal thoughts and behaviours has received little attention. However, the few studies in this area appear to suggest that recovery is a complex and an idiosyncratic process with many contributing factors. This can present a challenge for clinicians and services seeking to become more recovery focused. Thus, it seems of importance to develop a consensus on how recovery from suicidal thoughts and behaviours is conceptualised. Aim The study aimed to use the Delphi design to establish a consensus of how recovery is defined by those with lived experience of suicidal thoughts and behaviours. The Delphi method draws on the expertise of a panel, often involving clinicians, researchers and lived experience experts to develop consensus over a topic by inviting them to rate the importance of, often a series of statements to a given topic area. Method Lived experience experts were asked to complete two rounds of questionnaires distributed online to capture their views on recovery. Results A total of 196 individuals gave their views on the first round of the study and 97 gave their views on the second round. A final list of 110 statements was developed that 80% or more of participants defined as essential or important. Statements covered items that were important in defining, facilitation and hindering the process of recovery. Conclusion Findings are consistent with the wider literature that suggests that recovery is an idiosyncratic process, but with many commonly shared features. Here we also show that a comprehensive definition of recovery must include factors that hinder the process of recovery. Implications and recommendations for practice, policy development and future research are discussed.
... The interview guide has been structured around the CHIME framework. CHIME is an acronym, developed from a systematic review by Leamy and colleagues investigating the most important component in the recovery process (Leamy et al., 2011). The components are: 1) Connectedness, 2) Hope and optimism, 3) Identity, 4) Meaning and purpose, and 5) Empowerment (in a Danish context see (Santini et al., 2017)). ...
... The spaces should be sheltered from the surroundings but leave space for social meetings either by planting or roofed by existing shelter or a parasol (Ulrich et al., 2004). The purpose is to support the feeling of connectedness, which as described in CHIME is an important element in the recovery process (Leamy et al., 2011). ...
... These may be kitchen gardens that offer gardening work, such as removing weeds and watering the plants. Work tasks that are particularly requested by the elderly patients, and being assigned specific tasks in the garden as well as having the opportunity to do physical work can add to the important feeling of purpose in the recovery process (Leamy et al., 2011). ...
Full-text available
The increasing population and the aggregation of people in dense urban pockets add to the pressures on already complex and volatile global systems (WFP in Global food crisis, 2022). Food supply systems need to adapt and be resilient to not only natural phenomena such as climate change or the post COVID-19 crisis, but also in resistance to socioeconomic and geopolitical disturbances. The dependency of urban populations on external food systems makes these populations vulnerable to systemic breakdowns. This research looks at the looming food shortage in the UK (Bancroft in UK is ‘sleepwalking’ towards food shortages, farmers warn | The Independent in 2022), authors investigate design strategies for creating a more sustainable agrarian urbanism, which includes three classic urban utopias: Frank Llyod Wright’s Broadacre City, Kisho Kurokawa’s Agricultural City and MVRDV’s Pig City. Three case studies provide ideas and notions of creating a self-sufficient city in the post-colonial era of the UK. The design hypothesis responds to the increasing pressure from population and consumption growth, and the decreasing farming land and food suppliers. The final resolved urban farming system is based on existing conditions such as waste flows and underused spaces, it adopts novel design strategies and interacts with different elements of self-sufficiency to generate a network of farms with highly dense, multi-level structures.
... Mindfulness, cultivated through MBIs, is a highly relevant quality or skill for people with mental illness on their personal recovery journey. Personal recovery focuses on multi-facet personal and social outcomes, such as connectedness, identity, meaning, empowerment, hope, and optimism, which are individually defined and rated, beyond the reductionist focus on clinical and functional remission (Ellison et al., 2018;Leamy et al., 2011;O'Keeffe et al., 2022). This approach to recovery emphasises a holistic, person-centred approach that encourages individuals to understand and take responsibility to facilitate their recovery, which underpins global mental healthcare services (Bejerholm & Roe, 2018). ...
Full-text available
Objectives The current study was conducted to translate and validate the short version of the Kentucky Inventory of Mindfulness Skills (KIMS-Short) for the Chinese mental health population to examine the association between mindfulness and personal recovery. Method A sample of 434 community mental health service users completed the Chinese KIMS-Short and measures of self-compassion, psychological distress, and personal recovery. Results Results from the first- and second-order confirmatory factor analyses confirmed the five-factor structure proposed by previous research. Validity and internal consistency reliability of the 17-item Chinese KIMS-Short (KIMS-17) were evident. As measured by KIMS-17, mindfulness had moderate to strong correlations with self-compassion, stress, depression, anxiety, and personal recovery measures. Participants with experience in contemplation scored significantly higher overall and in all domains of mindfulness and personal recovery measures than those without experience. Additionally, participants who regularly engaged in contemplative practices scored significantly higher overall and in all domains of mindfulness and personal recovery measures, except for the describing mindfulness skill, compared to those who did not engage in practices. Conclusions The KIMS-17 is an appropriate brief and multidimensional mindfulness measure for people with mental illness, regardless of their level of experience in contemplative practice. Engaging in contemplative practices, whether rarely or frequently, may contribute to improvement in mindfulness and facilitate personal recovery.
... Personal recovery is commonly conceptualized via the 'CHIME' Framework. It consists of five interrelated processes: Connectedness with other people and the community; Hope and optimism about the future; overcoming stigma and redefining a positive sense of Identity; Meaning in life as defined by rebuilding a meaningful life with social goals; Empowerment, which includes taking personal responsibility and control over one's life [50][51][52][53][54][55][56][57]. The two concepts of recovery have led to some polarization in the understanding of what recovery entails [58]. ...
Full-text available
Introduction Patients with severe Major Depressive Disorder (MDD) have an increasing risk of new psychiatric hospitalizations following each new episode of depression highlighting the recurrent nature of the disorder. Furthermore, patients are not fully recovered at the end of their treatment in outpatient mental health services, and residual symptoms of depression might explain why patients with MDD have a high risk of relapse. However, evidence of methods to promote recovery after discharge from outpatient mental health services is lacking. The proposed scoping review aims to systematically scope, map and identify the evidence and knowledge gaps on interventions that aims to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care. Materials and methods The proposed scoping review will follow the latest methodological guidance by the Joanna Briggs Institute (JBI) in tandem with the Preferred Reporting Items for Systematic reviews and Meta-Analysis—extension for Scoping Reviews (PRISMA-ScR) checklist. The review is ongoing. Four electronic databases (Medline via PubMed, PsycINFO, CINAHL, and Sociological Abstracts) were systematically searched from 20 January 2022 till 29 March 2022 using keywords and text words. The review team consists of three independent screeners. Two screeners have completed the initial title and abstract screening for all studies retrieved by the search strategy. Currently, we are in the full text screening phase. Reference lists of included studies will be screened, and data will be independently extracted by the review team. Results will be analyzed qualitatively and quantitatively. Discussion The chosen methodology is based on the use of publicly available information and does not require ethical approval. Results will be published in an international peer reviewed scientific journal, at national and international conferences and shared with relevant authorities. Registration A pre-print has been registered at the medRxiv preprint server for health sciences ( ).
... Although courses in the Recovery College can be vastly different from one another, they all echo the CHIME (connection, hope, identity, meaning, and empowerment) principles. 5 Students opt for courses that are meaningful to them. Prior to the COVID-19 pandemic, most courses were carried out in-person with access to a library. ...
Full-text available
Recovery Colleges are strength-based mental health and well-being learning centers driven by peer support and principles of adult education. This paper examines the outcome of a hospital-based Recovery College in Canada on participants’ self-reported well-being, recovery, loneliness and self-esteem. Using a retrospective pre- and post- survey design and standardized scales, we collected self-reported data from 32 Recovery College students. The majority (88%) of participants were female and 78% of participants reported to struggle with maintaining positive mental health. Recovery College participation had a significant impact on self-reported connection, mental well-being, self-esteem, and personal mental health recovery.
... This was highly challenging to contain and hold the space at the very beginning for the DMP sessions. Hence, it was decided that with this group we would work towards identifying the existing strengths first so that they could use their resources to face and resolve their challenges and concerns (Leamy et al., 2011;McCaffrey et al., 2018). (2019), the intention ofthis principle was to support the caregivers to identify the roots of the challenges by unearthing past experiences and concerns. . ...
... Thematic analysis aims to identify emerging themes and subthemes and to facilitate the analysis and synthesis for each reviewed study (Clarke & Braun, 2014), thereby enabling the results of a review to be presented systematically and logically. In addition, we used the conceptual framework of Leamy et al. (2011) to synthesise our modified narrative (Popay et al., 2006). This framework comprise three stages, namely (1) the development of a preliminary synthesis, (2) the exploration of the relationship within and between the objects of a study, and (3) the assessment of the strength of a synthesis. ...
Research on in-service Science, Technology, Engineering, and Math (STEM) Teacher Professional Development (TPD) has received attention in the last decade, but has not produced conclusive findings. This study aimed to examine the trends of STEM TPD programmes by applying several proposed frameworks. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were employed to analyse 44 journal articles on in-service STEM TPD programmes. The results of this study revealed that constructivist theory was the most widely adopted learning theories. Moreover, workshop, training, and online TPD were the most frequently used learning models. The research conclusion indicates that future STEM TPD requires more involvement of school principals in encouraging STEM teachers to develop their professionalism through the necessary in-service TPD programs.
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Schizophrenia spectrum disorders (SSDs) are associated with significant functional impairments, disability, and low rates of personal recovery, along with tremendous economic costs linked primarily to lost productivity and premature mortality. Efforts to delineate the contributors to disability in SSDs have highlighted prominent roles for a diverse range of symptoms, physical health conditions, substance use disorders, neurobiological changes, and social factors. These findings have provided valuable advances in knowledge and helped define broad patterns of illness and outcomes across SSDs. Unsurprisingly, there have also been conflicting findings for many of these determinants that reflect the heterogeneous population of individuals with SSDs and the challenges of conceptualizing and treating SSDs as a unitary categorical construct. Presently it is not possible to identify the functional course on an individual level that would enable a personalized approach to treatment to alter the individual’s functional trajectory and mitigate the ensuing disability they would otherwise experience. To address this ongoing challenge, this study aims to conduct a longitudinal multimodal investigation of a large cohort of individuals with SSDs in order to establish discrete trajectories of personal recovery, disability, and community functioning, as well as the antecedents and predictors of these trajectories. This investigation will also provide the foundation for the co-design and testing of personalized interventions that alter these functional trajectories and improve outcomes for people with SSDs.
Introduction Psychiatric day-care services play a central role in community-based care in Japan. Recovery and related psychosocial factors are critical in promoting community participation of people with mental illness. This study aimed to reveal the relationships among activity information, personal recovery, and related psychosocial factors in day-care users. Method Forty day-care participants answered self-report questionnaires. The following assessments were applied: Recovery Assessment Scale, Occupational Questionnaire, Perceived Devaluation Discrimination Scale, and 26-item version of World Health Organization Quality of Life (QOL). The correlations among the factors were analyzed. Results Data for 35 people were analyzed. Total recovery score was strongly correlated with total WHOQOL-26 score ( r = 0.76, p < 0.001). Total QOL score was positively related with the value of activities ( r = 0.46, p < 0.05). Social QOL and total stigma score had a significant negative relationship ( r = −0.44, p < 0.05). Conclusion Participation in activities was suggested to improve QOL. Although there was a strong relationship between recovery and QOL, it was unclear to what extent participation in activities was related to recovery. We should consider approaches regarding other factors to fully accomplish community integration and personal recovery.
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Purpose: Sub-acute recovery-oriented facilities offer short-term residential support for people living with mental illness. They are generally highly regarded by consumers, with emerging evidence indicating that these services may support recovery. The aim of the current study was to explore the relationship between personal recovery and consumers’ satisfaction with sub-acute residential services, and consumers’ views about service features that aid recovery. Method: Consumers at nineteen adult Prevention and Recovery Care Services in Victoria, Australia, were invited to complete measures containing sociodemographic information and measures on personal recovery and wellbeing. After going home, participants were invited to complete measures on service satisfaction and experience. Results: Total and intrapersonal scores on the personal recovery measure increased significantly between Time 1 and Time 2, indicating marked improvement. Personal recovery and satisfaction measures were moderately to strongly correlated. Thematically analysed open-ended responses revealed themes of feeling connected, finding meaning and purpose, and self-empowerment as important aspects of these services, with some recommendations for improvements. Conclusion: Sub-acute residential services may support individuals’ personal recovery, be preferable and more cost effective than in-patient services. Exploring consumers’ experiences of sub-acute residential services helps to understand their effectiveness, opportunities for improvement and intended impacts on personal recovery.
Full-text available
In this paper the author proposes a new qualitative method for building conceptual frameworks for phenomena that are linked to multidisciplinary bodies of knowledge. First, he redefines the key terms of concept, conceptual framework, and conceptual framework analysis. Concept has some components that define it. A conceptual framework is defined as a network or a "plane" of linked concepts. Conceptual framework analysis offers a procedure of theorization for building conceptual frameworks based on grounded theory method. The advantages of conceptual framework analysis are its flexibility, its capacity for modification, and its emphasis on understanding instead of prediction.
Positive psychology is concerned with positive approaches to the development of individual and communal well-being. It acts as a counterweight to the concern with deficiency and failure evident in much psychology. Positive psychology has drawn together and is actively researching the impact of positive experiences and values on well-being and health. At present topics addressed include personal strengths, positive emotion, hope, forgiveness, optimism and flow for example. Though acknowledging the communal at present the bulk of work in positive psychology is still firmly oriented to the individual. In addition many proponents tend to champion an individualistic and often goal-oriented route to well-being. This focus will be contrasted with the authors empirical work on positive approaches to development and perceived effectiveness of a variety of individual and social strategies. This work highlights the importance of social, physical and non-reflective routes to the development of long-term well-being. In addition some organisations have adopted positive approaches to development. Research and policy implications will be discussed.
Recovery is a concept which has emerged from the experiences of people with mental illness. It involves a shift away from traditional clinical preoccupations such as managing risk and avoiding relapse, towards new priorities of supporting the person in working towards their own goals and taking responsibility for their own life. This book sets an agenda for mental health services internationally, by converting these ideas of recovery into an action plan for professionals. The underlying principles are explored, and five reasons identified for why supporting recovery should be the primary goal. A new conceptual basis for mental health services is described-The Personal Recovery Framework - which gives primacy to the person over the illness, and identifies the contribution of personal and social identity to recovery. These are brought to life through twenty-six case studies from around the world.
The concept of recovery has emerged as a central tenet of the mental health consumer movement, and is increasingly informing service development and evaluation. Key factors that contribute to recovery have been identified in both consumer writings and research, but few studies have explored the extent to which mental health workers and mental health consumers share perceptions of the relative importance of those factors. In this study a new instrument was developed to measure the importance of recovery factors as rated by paired mental health consumers and case managers. A pilot administration to 15 consumers and their case managers revealed that the measure was sensitive to differences in perceptions. Differences were found in the areas of medication, strengths-based interventions and perceptions of the relationship with the case manager and service. Case managers tended to rate their level of recovery-focused activity higher than did consumers. The instrument has potential to be used in a larger study to further establish its validity and reliability.
For doctors, trained and privileged to accept varying degrees of responsibility for another’s health problems, changing the terms can feel like a loss of personal identity for both parties. Recovery-oriented practice highlights the importance of the language we use and its relationship to personal
This hermeneutic phenomenological study examined the lived experience of African-American persons recovering from serious and persistent mental illness (SPMI). Semi-structured interviews were conducted at three time points (6, 12, and 18 months) with nine African Americans with SPMI. A culturally sensitive perspective informed the data analysis. Interviews were transcribed, read, and coded to cluster thematic aspects in each case and across cases. Atlas-ti was used to recode transcripts and retrieve quotes to dimensionalize each theme. Four themes were identified: (1) striving for normalcy, (2) striving to stay “up,” (3) coping with the consequences of illness, and (4) leaning on the supports that watch out for and over me. Findings were anonymously reviewed and critiqued by African-American research clinicians. Implications for practice include sensitivity to the intersection of racial oppression and stigma specific to mental illness, attention to meso- and macro-level needs, and client's positive responses to collaborative and personalized relationships with mental health professionals.